RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-00522
BRANCH OF SERVICE:  army	SEPARATION DATE:  20090712

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Cannon Crewmember, medically separated for “left shoulder evaluated analogous to arthritis, degenerative” and “left knee patellofemoral syndrome,” rated 10% each, with a combined disability rating of 20%.

CI CONTENTION:  Current condition supports a higher rating.  The complete submission is at Exhibit A.

SCOPE OF REVIEW:  The panel’s scope of review is defined in DoDI 6040.44.  It is limited to review of disability ratings assigned to those conditions determined by the Physical Evaluation Board (PEB) to be unfitting for continued military service, and when specifically requested by the CI, those conditions identified by the Medical Evaluation Board (MEB), but determined by the PEB to be not unfitting or non-compensable.  Any conditions outside the panel’s defined scope of review, and any contention not requested in this application, may remain eligible for future consideration by the Board for Correction of Military Records.  The panel’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections when appropriate.  The panel’s assessment of the PEB rating determination is based on review of medical records and all available evidence relevant to application of the Veterans Affairs Schedule for Rating Disabilities (VASRD) standards for the unfitting medical condition(s) at the time of separation.  The panel has neither the role nor the authority to compensate for post-separation progression or complications of service-connected conditions; that role and authority is granted by Congress to the Department of Veterans Affairs, which operates under a different set of laws.  The panel gives consideration to VA evidence, particularly within 12 months of separation, but only to the extent that it reasonably reflects the severity of disability at the time of separation.

RATING COMPARISON:

SERVICE PEB - 20090416	VARD - 20090720	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Left Shoulder Pain	5099-5003	10%	Status Post, Repair Rotator Cuff, Left Shoulder	5201	0%	20081219	
Left Patellofemoral Syndrome	5099-5003	10%	Patellofemoral Knee Syndrome, Left Knee	5299-5257	0%	20081219	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  80%  	

ANALYSIS SUMMARY:

Left Shoulder Pain.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s left shoulder pain condition began during a deployment in June 2007 while playing basketball.  On 24 October 2007, he underwent left shoulder Bankart and capsular shift procedures to relieve instability and pain.  Left shoulder X-rays on 10 January 2008 and 7 July 2008 revealed normal left shoulder socket, joints and humeral head without significant degenerative changes.  A 7 November 2008 MRI showed no joint effusion, fracture, dislocation, internal derangement, or rotator cuff/glenoid labrum tears.

At the 19 December 2008 VA Compensation and Pension (C&P) evaluation, 8 months before separation, the CI reported left shoulder pain, problems with overhead lifting, and pushing and pulling greater than 10 pounds.  Physical examination revealed no redness, swelling, heat, effusion, instability, deformity, muscle atrophy or tenderness.  Repetitive left shoulder range of motion (ROM) showed both flexion and abduction to 180 degrees (normal) with crepitus elicited by motion.  Rotator cuff integrity was intact with no weakness against resistance; there was no scapula examination.  A left shoulder X-ray was unremarkable.

At the 15 January 2009 primary care evaluation, 6 months prior to separation, the CI reported the inability to reach forward or lift over 5 pounds.  Physical examination revealed full, left shoulder ROM with pain, but no impingement or pain associated with the clavicle or scapula.
 
The 3 March 2009 MEB NARSUM examination, 4 months before separation, noted CI complaints of constant left shoulder pain. He could not elevate his left arm over his head or lift more than 2 pounds without significantly aggravating his pain.  Physical examination showed full ROM with the CI moving his arm very slowly and grimacing with discomfort during motion.  Left shoulder strength was good, but he hesitated to push forcefully against resistance because of the pain.  The upper arms had identical circumferential measurements.  During a 31 March 2009 physical therapy (PT) evaluation, 3 months prior to separation, repetitive left shoulder ROM was flexion to 145 degrees and abduction to 130 degrees, with painful motion.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the left shoulder condition 10%, analogously coded 5099-5003 (arthritis, degenerative), citing pain limited motion.  The VA rated the left shoulder condition 0%, coded 5201 (arm, limitation of motion), based on the C&P evaluation, citing full ROM with no additional limitation during repetition due to pain, fatigue, weakness or lack of endurance.  Members noted the VASRD §4.71a threshold for rating for ROM impairment under code 5201 is “at shoulder level” (approximately 90 degrees from the side), and the examinations in evidence demonstrated motion above this level.  However, a 10% rating was justified with application of VASRD §4.59 (painful motion) recorded by the MEB NARSUM and PT examinations.  There was no malunion or recurrent dislocation of the humerus to justify a rating under the 5202 code (humerus, other impairment); and no nonunion with loose movement of the clavicle to warrant the next higher 20% rating under the 5203 code (clavicle or scapula, impairment).  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded that there was insufficient cause to recommend a change in the PEB adjudication for the left shoulder condition.

Left Patellofemoral Syndrome.  According to the STR and MEB NARSUM, the CI’s left knee condition began in May 2007 after straining it during combat operations in Iraq.  On 10 January 2008, X-rays showed no evidence of fracture, effusion, or dislocation, but did show a nonossifying fibroma (bone lesion) of the distal femur.  A 22 January 2008 MRI showed normal anatomic knee alignment and no evidence of acute fracture or subluxation; bone marrow signal was normal and knee ligaments, patellar tendon, and cartilage were intact.  At a 26 February 2008 PT evaluation, the CI reported his left knee felt “100% improved” and he was “running pain free.”  Physical examination showed left knee tenderness and positive instability tests with pain, but there was no knee swelling and motion was “normal.”  At a case management visit on 4 June 2008, the CI reported left knee pain when he ran or stood for prolonged periods.  On 5 November 2008, X-rays showed normal anatomic left knee alignment with no fracture, subluxation, or acute osseous (new bone) abnormality; joint spaces were preserved and no effusions or significant soft tissue abnormalities were noted.

At the 19 December 2008 C&P evaluation, 8 months before separation, the CI reported left knee pain.  Physical examination showed a steady gait, and that the left knee was symmetrical to the right, with no redness, swelling, heat, effusion or deformity.  There was left knee tenderness, but no patella tenderness or crepitus.  The examiner noted no functional limitation with standing or walking, and no guarding with manipulation or ROM testing.  Motor and sensory functions were intact and meniscus and stability tests were negative.  Left knee ROM was 0-140 degrees (normal) without painful motion.

The 3 March 2009 MEB NARSUM examination, 4 months prior to separation, noted CI complaints of sharp, shooting pain located behind the left kneecap.  Physical examination showed tenderness of the patella and medial portion of the knee joint without crepitus.  Stability testing showed anterior cruciate ligament laxity with a solid endpoint.  Left knee ROM was 0-140 degrees, but painful motion was not addressed.  During the 31 March 2009 PT evaluation, ROM was 0-133 degrees without painful motion. 

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the left knee condition 10%, analogously coded 5099-5003 (arthritis, degenerative), citing painful motion.  The VA rated the left knee condition 0%, analogously coded 5299-5257 (knee, other impairment), based on the C&P evaluation, citing a noncompensable examination.  Members agreed there was no limitation of motion which supported a rating under the diagnostic codes for limitation of flexion or extension (5260, 5261).  There was no history or evidence of dislocated meniscus or loose body causing frequent locking with recurrent effusions (5258), to support a rating under that code.  There was no fracture, nonunion or malunion of the femur or tibia to support consideration under the respective codes for knee impairment related to long bone conditions (5255, 5262).  However, there was evidence of painful motion in the STR to support a 10% rating as adjudicated by the PEB.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded there was insufficient cause to recommend a change in the PEB adjudication for the left knee condition.  

BOARD FINDINGS:  In the matter of the left shoulder pain and IAW VASRD §4.71a, the panel recommends no change in the PEB adjudication.  In the matter of the left patellofemoral syndrome and IAW VASRD §4.71a, the panel recommends no change in the PEB adjudication.  There are no other conditions within the panel’s scope of review for consideration.  Therefore, the panel recommends no modification or re-characterization of the CI’s disability and separation determination.

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20170214, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record  

AR20180007162, XXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX

	The Department of Defense Physical Disability Board of Review (DoD PDBR) reviewed your application and found your separation disability rating and your separation from the Army for disability with severance pay to be accurate.  I have reviewed the Board’s recommendation and record of proceedings (copy enclosed), and I accept its recommendation.  I regret to inform you that your application to the DoD PDBR is denied.  

	This decision is final.  Recourse within the Department of Defense or the Department of the Army is exhausted; however, you have the option to seek relief by filing suit in a court of appropriate jurisdiction.

Sincerely,					      
Enclosure